OncoBlog: Firing Back at Single-Payer Notion

by Gary Jones, AA-C

When we published the article "Oncologists Call for Single-Payer System" earlier this week, we thought it would draw comments -- and it did, nearly 40 of them. One reader, Gary Jones, AA-C, sent a point-by-point commentary taking issue with the arguments made for the single-payer model.

A preponderance of evidence counters each of the eight problems Drs. Drasga and Einhorn claim a single-payer universal health insurance system could address.

1. Reduced administrative costs, which currently account for almost a third of healthcare expenditures. Medicare and Medicaid do not calculate administrative costs in the same manner that private insurers do, so the comparison confuses an honest assessment. When administrative costs are compared on a per-person basis, the picture changes. "Medicare's administrative costs were $509 per primary beneficiary, compared with private-sector administrative costs of $453. In the years from 2000 to 2005, Medicare's administrative costs per beneficiary were consistently higher than that for private insurance, ranging from 5% to 48% higher, depending on the year.

2. Eliminating many bankruptcies attributable to healthcare costs, which accounted for more than 60% of family bankruptcies. Simply put, catastrophic insurance would accomplish the same result, but, more interestingly, the claim that 60% of bankruptcies are attributable to healthcare costs may be inaccurate or at least misleading. According to the Center for Consumer Recovery, in 2013, 78% of bankruptcies filed were because of debt collection litigation, 74% reported they were pursued by a debt buyer, and 72% listed credit card debt as their primary unsecured debt.

Where do the authors get 60% of all bankruptcies were due to medical costs? In a 2007 study by Himmelstein et al., "when asked about problems that contributed very much or somewhat to their bankruptcy, 41.8% of interviewees specifically identified a health problem, 54.9% cited medical or drug costs, and 37.8% blamed income loss due to illness. Overall, 68.8% cited at least one of these medical causes. An additional 6.8% had recently borrowed money to pay medical bills." "Contributed somewhat or very much," identifying a health problem, and "income loss due to illness," have virtually nothing to do with insurance coverage or people going bankrupt secondary to the cost of out-of-control medical care. In addition, it is interesting to note that 78% of bankruptcy filers had some sort of medical insurance.

3. Improved health, as indicated by evidence that being uninsured increases the mortality hazard by 40%. While it makes sense that having some coverage would be better than none, the premise is false. The authors are comparing no insurance with having Medicare/Medicaid, not insured patients with Medicare/Medicaid patients. Besides the fact that a recent Oregon study found little difference in health outcomes between Medicaid patients and noninsured patients, the real comparison should be between publicly funded healthcare and private insurers, for which the data is voluminous and overwhelmingly states that outcomes and access are diminished with publicly funded healthcare compared with private insurance. Voluminous enough to show we should be discussing how to shift our Medicaid/Medicare patients to private insurers, not the other way around.

4. Building on an existing structure, noting that about 60% of all healthcare in the U.S. is publicly funded. The premise that just because it exists, we should build upon it makes little sense. Would we build a $100 million high-rise on a crumbling foundation? See the research in #3.

5. Implementation of proven cost-containment strategies, which are absent from the ACA. I am not sure what cost-containment strategies the authors are referring to, but as an architect of the HCA, Ezekiel Emmanuel's theory on the allocation of scarce medical resources would likely be referenced. For those who haven't read this paper, the complete lives system is an eye-opening view on medical treatment, in which at age 20 the probability of receiving medical treatment is at its peak, declining until age 50 then falling precipitously and becoming asymptotic to a zero probability of receiving medical treatment at ages over 70. One only needs to look at the Independent Payment Advisory Board (IPAB) in the current law to see that physicians and their patients would no longer be making decisions on what treatment would be chosen; some government agency would likely place severe restrictions based on cost and scarcity.

6. Improving quality of care and outcomes by increasing access to care. Again, see the research listed under #3.

7. Reverse the trend toward for-profit, investor-owned healthcare plans. Would this really be a good thing? I would argue that, based on the data I've presented here, we should be reversing the trend toward government funded healthcare and empower patients and expand choice and create a real national market for health insurance. Outside of Medicare and Medicaid, most people have little choice in their healthcare plans. Those who have a choice are often limited to a small number of health plans provided through their employer. Federal regulations make it difficult and expensive for companies to offer a large menu of health plans, and hefty tax penalties discourage employees from buying individual health plans. With the exception of consumer-driven health savings account (HSA) plans, tax laws encourage employer-sponsored health plans to set higher premiums -- that is, more third-party payment -- rather than implement incentives for efficient use of health services.

A 2005 McKinsey study discovered that patients in consumer-driven health plans were twice as likely to inquire about cost and three times more likely to select a cheaper treatment plan compared with patients in traditional plans. The tax laws and rules are wrongheaded. Regulations should be changed to allow more choices of health plans without tax penalties and greater use of HSA plans. This would encourage patients to make rational choices about day-to-day healthcare, while protecting them from the financial impact of truly serious illnesses and injuries. At the same time, competitive pressure from cost-conscious patients would reduce prices and improve quality for insurance-paid care, making everybody better off and rewarding providers who deliver quality care at lower prices.

Congress could further empower patients by creating a real national market for health insurance. Unlike the life insurance market in which a customer can buy any plan that he or she wants, patients can buy health insurance plans only in his or her state. States currently prohibit the purchase of health plans across state lines, and many states mandate costly benefit packages. These two restrictions combine to reduce consumer choice and increase costs and insurance rates in many states. Congress could pre-empt these limits using its constitutional power to regulate interstate commerce. Indeed, this power was written into the Constitution specifically to allow Congress to over-ride restrictions on trade among states. A real national market for health insurance would increase choices and reduce costs. People could buy policies tailored to their individual needs and preferences without states compelling them to purchase unnecessarily expensive coverage with mandated benefits they do not want. Patients would be free to choose between lower-cost catastrophic plans and higher-cost comprehensive plans, thus reducing the number of people who go without insurance due to high premiums.

8. Preserve physician's income potential, as judged by experience with the Canadian healthcare system. Did Drasga and Einhorn forget to convert from Canadian to U.S. dollars? Having worked with at least a half dozen Canadian physicians who have come to the U.S. for greener pastures, and doing a little digging, there is data refuting this claim. "The average income after expenses, in U.S. dollars, for an orthopedic surgeon in the U.S. was $442,450, compared with $208,000 in Canada, $324,000 in the U.K., and $154,000 in France. What is more, the U.S. has twice as many orthopedic surgeons per capita, providing about 35% more hip replacements overall. Primary-care physicians include family doctors, pediatricians, internal medicine specialists, and obstetrician/gynecologists. Those in the U.S. earned an average after expenses in 2008 of $186,582, versus $125,000 in Canada, $159,000 in Britain, and just $92,000 in Australia." I understand how emotional this subject can be to those who have dedicated more than a decade of education and training to helping others. In order to retain patient- and physician-driven medical decisions, reduce costs, increase good outcomes, and appropriately reimburse our physicians who have often taken on a quarter of a million dollars in debt, and made great personal sacrifices, we should be running from not running to government controlled healthcare.

Anyone in medicine who values evidence-based practice, one of our core competencies, needs only look at the evidence to see that an expansion of government controlled healthcare will hurt the healthcare system, the physician, and, ultimately, the patient.

As Hippocrates wrote in Epidemics, "The physician must be able to tell the antecedents, know the present, and foretell the future -- must mediate these things, and have two special objects in view with regard to disease, namely, to do good or to do no harm. The art consists in three things -- the disease, the patient, and the physician." While it may be impossible to actually see the future, do good and do no harm, nowhere does it speak of government's role in the art of medicine.

OncoBlog is a blog by the MedPage Today staff for readers with an interest in oncology. This post comes from guest-blogger Gary Jones, AA-C.

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